GID & the pathologization of transgender identity

On a beautifully sunny day in April 2004, I joined half a dozen members of the Gay Asian & Pacific Islander Men of New York (GAPIMNY) at the Manhattan offices of “Details,” a men’s magazine that had published an offensive feature entitled “Gay or Asian?” that mocked gay Asian men as effeminate and undesirable. After a successful meeting with the editor and publisher, we went to the Manhattan Mall nearby on Sixth Ave. at 33rd Street for lunch; we were delighted to have gotten an apology from them and a promise that “Details” would run a formal apology in the next issue of the magazine. While my colleagues were having lunch in the food court in the basement, I went to the women’s room; when I came out, I was surrounded by security guards who stood around me in a menacing stance, demanded to know if I was a man or a woman; the five men were big and menacing; the one woman among them seemed to have some authority, and when I suggested to them that they were risking a discrimination lawsuit, she had the others return to their station behind a one-way window just down the hall from the women’s restroom. While a bit shaken, I demanded to see her supervisor, who came out a few minutes later. After reconnoitering with my colleagues in the food hall, who were curious as to why I had disappeared for such a long time, we left the Manhattan Mall. When I got home, I called my colleague, Michael Silverman, then the executive director of the Transgender Legal Defense & Education Fund (TLDEF) to enlist his support.

My experience of discrimination in the Manhattan mall on that day in April 2004 was not that different in character from countless such incidents of discrimination based on gender identity and expression that transgendered and gender-variant people have had over many decades in the United States and throughout the world; what was different was that I was a transgender activist who had led the campaign for the transgender rights law enacted only two years earlier in April 2002 and at the time of the incident in April 2004 was a member of the working group meeting at the New York City Commission on Human Rights engaged in drafting guidelines for implementation of that transgender rights law. Having written the statement of legislative findings and intent, I knew the new law as well as anyone; and given my participation in the working group at the Commission, I also knew that status of the guidelines at that moment.

The working group was actually at an impasse over the language to use to describe possible situations involving discrimination in sex-segregated facilities requiring nudity such as gyms and locker rooms. Michael Silverman represented me in legal action against Advantage Security, the private firm that provided security for the Manhattan Mall; at the same time, I filed a complaint on my own with the Commission, meeting with a staff attorney who did not know about my participation in the working group working to draft the implementation guidelines for the transgender rights law. After some discussion between TLDEF and Advantage Security, they agreed to settle, making a donation to the New York Association for Gender Rights Advocacy (NYAGRA) at my request as well as having their security guards undergo transgender sensitivity training. Ironically, the language that Michael Silverman and I worked out for the Advantage Security settlement helped us resolve the impasse within the working group and the Commission on Human Rights incorporated that language into the draft of the guidelines adopted by the Commission in December 2004.

TLDEF announced the settlement of my case as well as that of Justine Nicholas on 31 March 2005 and the New York Times reported on our settlement, Nicholas Confessore writing,

When Pauline Park watched Mayor Michael R. Bloomberg sign an amendment toughening the city’s anti-discrimination laws two years ago, she never expected to become one of its first beneficiaries. But yesterday, a complaint filed by Ms. Park – a co-chairwoman of the New York Association for Gender Rights Advocacy, which helped lobby for the amendment to the New York City Human Rights Law – became part of the first settlement issued under it… (Nicholas Confessore, “Transgender Group Reaches Agreement on Restrooms,” New York Times, 2 April 2005).

A New York Times story tends to attract attention from both friends and foes, and so it was with this one. Among the most influential of the organizations on the religious right is the Traditional Values Coalition. TVC attacked the settlement that I reached in April 2005 in my discrimination case, not in the least bit impressed by the fact that I was the first (along with Justine Nicholas) to successfully pursue a discrimination claim under the transgender rights law enacted by the New York City Council in 2002. In response to the report by the e Traditional Values Coalition declared on April 7 of 2005,

“The New York Association of Gender Rights Advocacy has won a victory over restroom use by individuals who believe they are a member of the opposite sex… The victory involves a settlement from a security guard company that allegedly discriminated against transgender activist Pauline Park when he [sic] used a woman’s restroom in a Manhattan mall in April, 2004. Park wears women’s clothing and identifies as a woman but has not had a sex change operation. Park is still anatomically a male but calls himself [sic] a ‘male-bodied woman’… This decision means that men who think they are women and are still anatomically males can use women’s restrooms in New York City…”

The April 7 TVC news report is entitled, “Ladies Restrooms: Who is That Male-Bodied Woman In the Next Stall?” That report concludes, “In a society where rational thought still existed, Pauline Park would be institutionalized for insanity or be given intense therapy to overcome his [sic] serious gender identity disorder. Instead, he has imposed his own mental illness upon the city of New York — and Michael Bloomberg has been a willing accomplice…”

That TVC ‘news report’ (if one could call such an absurd expression of prejudice a ‘news report’) brought home to me the profound significance of the continuing pathologization of transgender identity of gender variance and transgender identity. The ‘gateway’ diagnosis required to access to hormone replacement therapy (HRT) and SRS from 1974 until 2013 was gender identity disorder (GID), introduced into the fourth edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM IV), published by the American Psychiatric Association (APA). While GID is usually thought of as the diagnosis by which adult transsexual and transgendered people gain access to HRT and SRS, the true significance of GID is much larger. First, a change of legal sex designation the ‘gender marker’ on identification documents that assigns us to either male or female sex in most jurisdictions requires at the very least documentation of an intent to go for SRS, if not actually proof of completion of surgery (as is the case in New York City).

While there is no necessary connection between a change of legal sex designation and a change of legal name, in many if not most cases, transitioning transsexuals pursue these two changes simultaneously. The truth is that most transgendered people frequently or even consistently present in a gender that does not match their ID, which causes problems in a multitude of situations. Since 911, most large buildings in New York City require photo ID even to enter the building. And so the apparent discrepancy between ID and either ‘gender marker’ and/or gendered name and/or gender presentation in a photocan constitute a barrier to employment, housing, and public accommodations as well as to accessing health care and social services.

But if the apparent ’solution’ is to go for a change of legal sex designation as well as name, and if the former change – and in some cases, effectively, the latter – requires a diagnosis by a psychiatrist; then in effect, the ability to access health care as well as employment, housing, and public accommodations requires such a diagnosis as well. I personally find it outrageous that transgendered people in the United States and elsewhere have to have themselves declared mentally ill in order to access health care or to get or to keep a job. We must commit to finding means by which transgendered people can access forms of medical intervention such as HRT and SRS without having to subject themselves to the degradation of being declared mentally ill simply by virtue of their gender identity.

GID not only undergirds the Harry Benjamin Standards of Care (SOC) and the protocols for gender transition in this society, this diagnosis – what I call the GID ‘regime’ – constitutes the very basis for American society’s understanding of transgender. Even in relatively more sympathetic portrayals of transgendered characters such as those in “TransAmerica” and on “All My Children” and “Ugly Betty,” the discourse through which those characters are understood is a medical model of transsexuality based fundamentally on the concept of gender dysphoria. My own work as a transgender activist is informed by a feminist conception of gender and a commitment to challenging and dismantling the sex/gender binary that is at the root of our oppression as women and as men as well as transgendered men and women or for that matter, genderqueers who resist binary categorization. Our goal as a movement must therefore be nothing less than the transformation of society’s understanding of gender. And if we are committed to that goal, we must also be committed to dismantling the ‘GID regime’ that undergirds this system of gender regulation and control.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), for a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and his or her assigned (natal) gender, and it must continue for at least 6 months. In children, the desire to be of the other gender must be present and verbalized. The condition must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning,

“The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People formulated by the World Professional Association for Transgender Health (WPATH-SOC), [2] formerly known as the Benjamin Standards of Care, outline a 2-phase diagnostic process for patients seeking sexual reassignment surgery (SRS): Phase I – A formal diagnosis is made according to accepted criteria; risk factors are estimated to ensure that the individual can tolerate the life changes that SRS will bring. Phase II – The ability to live in the desired sex role is tested; the family is informed, and the patient’s name is changed; assessment of whether to administer hormone therapy is made; psychotherapy is required.

For adolescents seeking SRS, the following requirements are added: The patient must show a lifelong cross-gender identity that increased at puberty. Serious psychopathology must be absent. The person must be able to function socially without significant problems. Psychological intervention may be beneficial. Individual treatment focuses on understanding and dealing with gender issues. Group, marital, and family therapy can provide a helpful and supportive environment. Hormone therapy may also be necessary. Agents that may be considered include luteinizing hormone–releasing hormone (LHRH) agonists, progestational compounds, spironolactone, flutamide, cyproterone acetate, ethinyl estradiol, conjugated estrogen, and testosterone cypionate. SRS may be appropriate for selected patients… (ibid)

Scores of clinicians worked on the revision of the definition of GID, producing what on the face of it looks like a significant advance in the DSM-5’s definition of ‘gender dysphoria.’ And yet, a closer examination will show that the ‘advance’ is more apparent than real. It is certainly true that the harshly pathologizing language of the DSM-4 has been considerably softened and by the standards of the original GID diagnosis, that of gender dysphoria seems almost value-neutral in comparison. Unfortunately, much of the language is either ambiguous or clumsy or absurdly clinical; e.g., what exactly is a ‘sex role’? Is a ‘sex role’ different in any way from a ‘gender role’? But beyond such awkward phraseology, there are several important points to be made about the DSM-5’s characterization of ‘gender dysphoria.’

First, the definition of gender dysphoria is still based on the sex/gender binary, and both the diagnosis and the prescribed treatment are clearly based on the notion that one transitions in a linear fashion from male to female or female to male; there is no recognition whatsoever of gender variance such as ‘genderqueer’ identity that is non-binary. Second, the psychiatrist remains the ‘gatekeeper’ without whose permission hormone replacement therapy (HRT) or sex reassignment surgery (SRS) are permitted. Third, the definition of gender dysphoria seems to require ‘clinically significant distress.’ And fourth and most importantly, this medicalized model of transsexuality is still based on the notion of pathology, regardless of the softening of the language; the fact is, the whatever language is used, the definition of gender dysphoria would still be in the Diagnostic and Statistical Manual of Mental Disorders, meaning that the inclusion of any definition of GID or dysphoria would necessarily characterize transgender identity and gender variance as a psychopathology.

One may well ask, what if a transgendered person feels no ‘clinically significant distress’? Or perhaps more to the point, what if the ‘distress’ is not caused by the person’s gender identity but rather from the transgenderphobia that individual faces in society? And on a practical level, the characterization of transgender identity as a mental disorder does not admit of the possibility of a purely social transition in which no medical intervention is desired.

I fully understand the practical implications of GID for accessing hormones and surgery, but I think we need to question the notion that we must accept the pathologizing of all gender variance as mental illness in exchange for the ostensible benefits that flow from the diagnosis. The reality is that many and perhaps even most of those who have gotten SRS paid for by private insurance in the United States in the last decade have been able to do so under the auspices of the Affordable Care Act, legislation whose future is extremely insecure given the public commitment of Barack Obama’s successor Donald Trump and the Republican majorities in both houses of Congress to repeal the ACA. One might also point out parenthetically that there was no provision in ‘Obamacare’ (as the ACA is popularly known) that explicitly prohibited discrimination in the provision of health care on the basis of gender identity or expression (or sexual orientation, for that matter), nor was there any provision that explicitly required health insurance companies from covering HRT or SRS for transitioning transsexuals. The very fact that insurance payment for HRT and SRS appear to be dependent on the fate of controversial legislation opposed by the majority party in the United States itself would seem to be a compelling argument to re-examine the very notion of retaining a pathologizing diagnosis in the DSM simply to secure continued insurance payment for those medical interventions. And it must also be pointed out that, despite the ACA, many transgendered people continue to have no health insurance at all, and those who do have either Medicaid, whose budget is more precariously perched than that of any other major federal entitlement program.

If Republicans in Congress are successful in ‘repealing and replacing’ the ACA, then the reversion to the status quo ante could well mean that those who get health insurance through health maintenance organizations (HMOs), most of which had explicit clauses written into their policies excluding coverage of any service related to gender transition, could well find themselves unable to access insurance coverage for HRT and SRS as in the era before Obamacare.

What is striking to me is the narrow parameters of the debate within the transgender community and even within the larger LGBT community over the role of the diagnosis of GID and its successor, gender dysphoria, in accessing HRT and SRS; there has been virtually no discussion in LGBT contexts of the fact that the United States is the only industrialized democracy in the world without universal health care. It seems to me that rather than fighting for private insurance coverage for medical interventions related to gender transition, we in the transgender community and the larger LGBT community should instead be demanding universal health care and statute laws that explicitly prohibit discrimination in the provision of health care based on gender identity and expression as well as sexual orientation; doing so would enable us to connect the struggle for transgender access to health care to the larger national debate over universal health care; doing so would also enable the transgender community to forge real relationships and alliances with other communities fighting for health care rather than characterizing the issue of transgender health care narrowly as a fight for HRT and SRS through a pathologizing definition of transgender identity under the rubric of disability.

It is important at this point to talk about the impact of pathologization and to recognize the fact that the pernicious effects of GID extend far beyond simply the instrumental necessity for adult transsexuals to obtain the diagnosis in order to access hormones and surgery. According to one report, three quarters of all those diagnosed with GID are diagnosed with GID in childhood and adolescence. These are for the most part gender variant children whose parents take them to a psychiatrist because Johnny is playing too often with dolls or Janie is climbing too many trees. The parents conflate homosexuality with transgender and hope that the psychiatrist can ‘cure’ or at least ‘prevent’ homosexuality in their chil dren. There may well be a significant segment of the psychiatric profession that uses the diagnosis in precisely this fashion to try to ‘cure’ or ‘prevent’ homosexuality in children and youth – this, despite the removal of homosexuality from the DSM in 1974.

Many of these psychiatrists, such as Charles Socarides and George Rekers, are associated with the religious right and in fact advocate re introduction of homosexuality in the DSM. Rekers, who is on the faculty of the School of Medicine at the University of South Carolina, has in fact received over half a million dollars from the National Institute of Mental Health (NIMN) to study ways to ‘treat’ and ‘cure’ such ‘deviant’ behavior, including ‘at ypical gender identity,’ ‘atypical sex roles,’ and ‘pre transsexual behavior.’

One of the leading organizations advocating re introduction of homosexuality in the DSM is the National Association for Research & Therapy of Homosexuality. NARTH and their co conspirators in homophobia see removal of GID as having the potential to eliminate the ability of psychiatry and homophobic and transgenderphobic parents to police and enforce the gender boundaries that they wish to impose on their children as well as on adults to the extent possible.

I have an Asian American lesbian friend in Queens whose nephew is transgendered. When he told his parents that he felt himself to be a girl, his mother and stepfather had him institutionalized, on the basis of a diagnosis of GID. He is currently at Cinnamon Hills, which despite its charming name, is in effect a prison for youth located in the middle of the desert in southern Utah. Perhaps the most famous such case of institutionalization of a youth with GID is that of Daphne (now Dylan) Scholinski, who now identifies as a transman. At fifteen years old, Scholinski identified as a butch lesbian and was committedto a mental institution by parents who were determined to ‘cure’ her ofthe mental illness with which she was diagnosed. The Last Time I Wore A Dress is only the most famous account of a gender-variant youth subjected to behavior modification therapy for a gender identity that is no disorder and that cannot be cured.

What many people evenwithin the transgender community do not realize is that legal minors can be committed to a mental institution and subjected to behavior modification therapy up to and including electroshock therapy. In fact, even adults can be institutionalized against their will if they are diagnosed with GID, which is precisely what happened to the renowned economist Deirdre McCloskey, when family members decided that she was ‘insane’ after she told them of her intention to transition (as she writes in Crossing: a Memoir, University of Chicago Press, 1999). It seems to me that what is ‘insane’ is forcibly institutionalizing a brilliant economist simply because she has informed her family that she wishes to live her life consistent with her internal sense of gender identity. What is insane is the diagnosis of GID itself.

The pernicious effects of GID extend by implication indirectly to the intersexed as well. Intersex genital mutilation (IGM) certainly requires no diagnosis of GID, and in fact, the intersex ‘condition’ is explicitly excluded as a criterion for GID, but the rigid insistence on the sex/gender binary articulated by the GID diagnosis that is officially recognized by the psychiatric profession through its inclusion in the DSM gives implicit support to the practice of IGM.

The influence of GID also extends into the sphere of public policy as well, impeding the fight for transgender rights. We have made enormous progress as a community and as a movement over the course of the last two decades, but while 95 jurisdictions including nine states and the District of Columbia – now have enacted legislation explicitly prohibiting discrimination based on gender identity or expression, it is a sad fact that 41 states have no such protection in their state laws. However, every state has included disability in its human rights law, and it is that rubric that litigators are using to obtain legal redress for transgendered plaintiffs across the country, and they often win on that basis. But the argument that such litigators proffer usually follows along these lines: my client is mentally ill by virtue of his/her gender identity disorder and therefore is protected under state disability law. I should make clear that I have nothing but admiration for the hard working lawyers who represent transgendered clients – often pro bono – with limited time and resources. And in those 41 states without explicit inclusion of gender identity and expression in state human rights law, appeal to disability by way of GID may well be the only practical way of obtaining legal redress for discrimination against a transgendered client. But I think we need to recognize how sharp the horns of that dilemma may be.

As a non lawyer who works on legislation, I can tell you that the genuine happiness that I feel for the transgendered client who wins such a case is diminished by the realization that the victory for that individual undercuts the very arguments that we need to make in the legislative arena. Because it is precisely GID that gives the religious right and other opponents of transgender rights legislation their most powerful ammunition.

Consider Vermont, where activists are trying to get the state legislature to pass a transgender rights bill against the opposition of right -wing organizations such as Vermont Renewal, which describes itself as “a grassroots organization with the primary goal of promoting and defending traditional family and moral values based on the Judeo- Christian worldview that Vermont and the entire United States were founded upon” (www.vermontrenewal.org). In an op-ed in the Burlington Free Press for Vermont Renewal, Stephen Cable writes,

“Under the banner of equality, the Vermont Legislature seeks to protect transgender behavior (i.e. transvestite and transsexual) from discrimination (bills S.51 and H.228)… Despite good intent, there are major problems with this legislation. First, such behavior is associated with a treatable mental disorder. However, we question efforts which, under the pretext of equality, actually favor one mental disorder for protections to the exclusion of all others, such as depression, anorexia, kleptomania, etc. The Common Benefits Clause of the Vermont Constitution forbids such preferential treatment…”

Cable continues,

“There are, of course, serious pitfalls associated with efforts to protect behavior associated with mental disorders. Perhaps the largest would be inadvertently sending a message that such illness is healthy, or even desirable, rather than encouraging treatment and recovery – thereby trapping people within this disorder. Equally important, however, is the danger that, by affording too much protection to the sufferer, government may actually become the oppressor, creating unforeseen hardship and complexity for businesses, schools, and the common person…” Now, there are certainly many responses to Cable’s uninformed and bigoted screed, including a critique of the way in which he misconstrues disability law and how it works. And one can also respond to Cable by pointing out that there is no evidence that the GID diagnosis was intended to be used as an argument against non-discrimination legislation. But we simply cannot ignore the fact that the religious right not only in Vermont but across the country has latched onto GID as the core of its argument against transgender rights legislation at the local, state and national levels; to that extent, the removal of GID from the DSM would disable their core argument (pun intended). And any student of LGBT history would be conscious of how the removal of homosexuality from the DSM in 1974 advanced the gay and lesbian movement from that point onwards.

What I would say to the Traditional Values Coalition is this: I do not have a gender identity disorder; it is society that has a gender identitydisorder. I must admit it was a bit of a shock to be subjected to personal attack by one of the largest religious right organizations in the country, but I have taken the advice of a friend of mine who encouraged me to wear it as a badge of honor. Now that I’ve been declared a public enemy by the likes of TVC that I have ‘arrived.’

But the point I would like to make here is not so much about the TVC bull’s eye on my forehead; it is the ammunition that the discourse of mental pathology gives to opponents of transgender rights. In TVC’s report, “A Gender Identity Disorder Goes Mainstream” (also issued in April 2005), the organization declares, “These are deeply troubled individuals who need professional help, not societal approval or affirmation.”

Elsewhere in its ‘report,’ TVC describes “this mental illness and how it is being normalized in our culture.” In fact, the very title of the TVC ’special report’ is “A Gender Identity Disorder Goes Mainstream,” followed by the sub head, “Cross dressers, transvestites, and transgenders become militants in the homosexual revolution.” And TVC is not the only such organization pursuing this line of argument, however specious. The religious right is now so panicked about the growing acceptance of gay men and lesbians in this societythat they are increasingly focusing on the diagnosis of GID not only to oppose transgender rights legislation, but also non discrimination andhate crimes legislation that includes sexual orientation as well.

And that is why I say that every victory for a transgendered plaintiff whose lawyer uses disability to win a discrimination case compromises our ability to work in the legislative arena – hence my profound ambivalence about the GID-based arguments being used in such cases. A few years ago, I had a conversation with a transgender activist from another state for whom I have great respect. She insisted that the way forward for the transgender movement was the disability route. I insisted with equal vehemence that the ‘disability track’ was the wrong path to pursue. I cited the clause in the Americans with Disabilities Act that explicitly excludes ‘transvestism and transsexualism’ from coverage under the terms of the 1990 federal disability rights law, thanks to Jesse Helms. The notoriously bigoted senator from North Carolina made certain that the path to transgender rights through federal disability law would be closed, and there is little if any chance that that path will be opened anytime soon.

But the issue of federal disability law aside, the larger strategic question for our community and for our movement must be this: is our goal only litigation and legislation or are we pursuing something bigger? The whole critique of the queer left of the mainstream gay and lesbian movement is that it has for far too long focused narrowly on juridical rights. Now, I happen to believe that we should pursue non-discrimination legislation and that we must ensure that all transgendered and gender variant people – indeed, all LGBT people – gain equal rights under federal as well as state and local law in every area of activity, including marriage. But I also believe that our movement must have at its core a vision of social justice and social change. And that vision must be premised on the goal I articulated earlier. Our objective must be nothing less than the transformation of society’s understanding of gender. And so the removal of GID from the DSM must be a goal of our movement; it simply cannot be otherwise. We must discard a medical model of transsexuality that is a disease model of mental illness; we must reject any suggestion that our goal as a community and as a movement is simply to find a place within a normalizing discourse of the existing sex/gender binary, expanded ever so slightly to accommodate us – or at least those of us who can comfortably fit within a governing regime of heteronormativity. In its stead, we must embrace a vision in which all forms of transgender are seen simply as natural variants in gender identity and expression and in which all transgendered and gender variant people will be accepted as fully equal to their conventionally gendered family members, friends, colleagues, and neighbors.

It is important at this point to address the misunderstandings that have arisen when I have discussed the need for the depathologization of transgender identity and gender variance in speeches that I have given since 2007, when I called for the abolition of GID in my keynote address at the Philadelphia Trans-Health Conference (“Transgender Health: reconceptualizing Pathology as Wellness,” 7 April 2007) and in a talk at Harvard University’s School of Public Health in Boston in 2011 (“Transgender Health, Pathology and Human Rights,” 20 April 2011). When I spoke at Harvard, one graduate student in the audience asked me if I was advocating that the transgender community disassociate itself from the disability community; this student misinterpreted my comments as suggesting that transgendered people should distance themselves from people with disabilities because of the stigmatization of people with disabilities (mental as well as physical) in American society. In fact, I think we should work to end the stigmatization of all forms of disability, whether mental or physical; and I think an alliance between transgender activists and disability rights activists would be a very good thing indeed; but that relationship cannot be based on a false pathologization of transgender and gender variance. The real basis for an effective working relationship between the transgender community and other communities, including the disability community, would be precisely the rejection of the false notion that transgender is a psychopathology, the objective of ending the stigmatization of all forms of disability.

What I would like to suggest as an alternative is to put a concept of wellness at the center of transgender health. I am arguing here for the removal of transgender identity from the DSM altogether and a comprehensive rejection of the pathologizing of transgender and gender variance. Just as homosexuality is now viewed by mainstream psychiatrists and psychologists as simply a natural variance in sexual orientation, so transgender would be viewed simply as a natural variance in gender identity and expression – no more or less natural than conventional gender identities.

The objection to such a conception coming from certain quarters no doubt would be that it would render hormone replacement therapy and sex reassignment surgery as ‘elective’ procedures, thus making it impossible to get insurance payment for HRT and SRS as ‘medically necessary.’ But I would argue that we must challenge the very notion that as transgendered people we should view ourselves as having been born with a ‘birth defect’ and instead see ourselves as being fully natural and fully human just as in fact we are.

In this conception, the various technologies that some of us use to modify our anatomy and biology would be viewed as technologies of self-determination, used to configure our bodies to conform to our internal sense of gender identity. In other words, HRT and SRS, breast reduction and breast augmentation, metoidioplasty, tracheal shaves, and other forms of plastic surgery would be technologies we can use to make ourselves feel more comfortable in our own skin – technologies that we can use to enhance our sense of well-being. In such a conception, would hormones, surgery and the like be elective? Yes, and by reconceptualizing such technologies as elective, we would reclaim our sense of self determination. The truth is that the argument for SRS as currently conceived makes no sense whatsoever. For what mental illness is surgery on a part of the body other than the brain indicated or prescribed? I know of none. The usual objection to SRS is that it involves the removal (in most cases) of perfectly healthy tissue, and that is in fact usually the case. There is nothing diseased in the sex organs of most transsexual or transgendered people who seek SRS. But surgery will enhance the well-being of those who elect it. And by reconceptualizing surgery – including and above all SRS – as elective, we reclaim our sense of agency. The notion that SRS is medically necessary cannot be advanced except by way of an argument that pathologizes our bodies and our minds – that pathologizes our very identities.

The truth is that SRS is rafely if ever medically necessary in the conventional sense of the term. Rather, SRS can be a very effective way of enhancing the well-being of those who elect it, and as such, should be readily available without any psychiatric evaluation or diagnosis to those who choose to elect it. And just as private insurance pays for hormone replacement therapy for post menopausal non transgendered women, it should pay for HRT for transgendered women and men as well as for SRS for both. The crucial point is that we as transgendered individuals have to move towards acceptance of ourselves. And we as a transgender community have to reject the idea that the body of a transgendered person is a diseased body. Even more importantly, we must reject the notion that the mind of a transgendered person is a diseased mind. The ‘problem’ of ‘gender dysphoria’ is not to be found in the mind of a transgendered person. Rather, the problem is to be found in the society that is too rigid to allow for those born male to identify as women or those born female to identify as men – or to allow those born male, female, or intersexed to identify as something other than men or women.

And so I say that what we need to do is to reconceptualize pathology as the problem and not the solution to our problems. The solution is, instead, a (w)holistic concept of wellness informed by feminist consciousness that locates the problem at the level of society and not the individual who resists the dictates of an overly gender-rigid society. As I see it, my work as a transgender activist is not about helping a small number of post-operative transsexuals to fit more easily into existing boxes but rather about helping all of us to break out of all of the boxes so that we can all be whoever and whatever we feel ourselves to be. In my view, the task facing us as a community is not to shore up regressive notions of mental pathology but rather to challenge and dismantle the GID regime and the larger sex/gender binary of which it is a part and which is the source of our oppression as transgendered and gender variant people. We must set as our objective nothing less than the transformation of society’s understanding of gender, as part of a movement for social justice for all.

Reconceptualizing the struggle for transgender health care access in progressive feminist terms is part and parcel of engaging in the struggle for universal health care, which can only be based on a ‘single-payer’ system administered by the federal government. The question of the precise form of that system of health care lies well beyond the parameters of this chapter but could certainly involve ‘Medicare for all,’ to cite just one possible option. But what is crucial is that we move from the limiting conceptualization of our work as transgender activists as being about securing access to HRT and SRS through use of the Americans with Disabilities Act (ADA) on the basis of transgender identity as a mental illness and instead recast our struggle as part of the larger struggle for universal health care with guarantees prohibiting discrimination in its provision on the basis of gender identity and expression as well as sexual orientation; by doing so, we can make common cause with other groups and communities.

I urge you to join me in that struggle. Thank you.

In 2004, I named and co-founded the Transgender Health Initiative (THINY), a joint project of the New York Association for Gender Rights Advocacy (NYAGRA) and the Transgender Legal Defense & Education Fund (TLDEF) whose mission was to enhance access to health care for transgendered and gender-variant people. When we began a series of monthly membership meetings that continued for a few years, we expected that THINY members would want to begin by working with hospitals that were part of the Health & Hospitals Corporation of the City of New York, which were and still are underfunded and desperately in need of transgender sensitivity training; we were surprised to discover that THINY members actually wanted to address issues of transgender sensitivity — or lack thereof — at the Callen-Lorde Community Health Center; we were surprised because Callen-Lorde is the lesbian, gay, bisexual and transgender (LGBT) community health care provider in New York and may well have more transgendered clients than any other health care provider in the city.

But our transgendered members had many complaints about Callen-Lorde and their experiences there, and so we launched a project collaborating with management at Callen-Lorde to survey transgendered patients and clients on their experiences there; we designed the survey, which was made available on-line and in paper form at the front desk, and we got a significant rate of return. As a result of the very candid feedback from the survey, we were able to make recommendations to the administration, which in turn created a transgender community advisory committee as well as hiring for a new position of transgender services coordinator. Following our work with Callen-Lorde, we then began to work with senior management at HHC, though it was the inability to get a commitment to a budget for training that prevented us with moving forward on training for HHC personnel. (At the same time, Gouverneur, one of the HHC hospitals, was moving forward with a small LGBT health clinic.)

In 2009, I worked with NYAGRA’s summer intern, Kelly White, to put together the first directory of transgender-sensitive health care providers in New York City and the metropolitan area (which is now available on-line at transgenderrights.org). Published in July of that year, this was the first directory of transgender-sensitive health care providers for New York City and the metropolitan area ever published, and to my knowledge, it was the first such directory for any city published in a print edition anywhere in the United States.

In 2006, I did a series of trainings with Michael Silverman (then executive director of TLDEF) for St. Vincent’s Hospital, which was one of the largest hospitals in New York City, and a hospital with one of the largest transgender patient populations; these were the first transgender sensitivity trainings at any major hospital in the city. Sadly enough, St. Vincent’s went bankrupt in 2010 and closed after failing to resolve a situation in which the hospital had accumulated over a billion dollars in debt. These transgender sensitivity trainings were as much of an eye opener for us as they were for the nurses, techs, and other health care professionals we trained. Participants ranged from hostile to indifferent to open-minded to genuinely supportive in short, a microcosm of society and its attitudes towards the transgendered. Only a few of the nurses were openly hostile and even (in at least two cases) somewhat disruptive. But most of the nurses and other providers we did trainings for at the very least listened politely.

The real problem was the lack of both knowledge of the challenges facing transgendered people as they try to access health care as well as the lack of sensitivity on the part of some of these providers. With regard to the former lack of knowledge one of the big problems facing our community is that among those who think about transgender access to health care and there are far too few who think about this issue at all most imagine that the main challenge we face is accessing hormones and sex reassignment surgery (SRS). While that is a challenge, the biggest challenge for transgendered people really is accessing healthcare for all of those medical issues unrelated to gender transition.

And that leads me to the central theme of this chapter. The work that I have done in New York on health care access for members of the transgender community has made very concrete the many paradoxes and dilemmas of advocating simultaneously for health care access and for human rights in the face of the pathologization

(photo courtesy Anh Ðao Kolbe)

Pauline Park is chair of the New York Association for Gender Rights Advocacy (NYAGRA), the first statewide transgender advocacy organization in New York (www.nyagra.com), which she co-founded in June 1998. She also serves as vice-president of the board of directors of the Transgender Legal Defense & Education Fund (TLDEF). Park led the campaign for the transgender rights law enacted by the New York City Council (Int. No. 24, enacted as Local Law 3 of 2002). She served on the working group that helped to draft guidelines – adopted by the Commission on Human Rights in December 2004 – for implementation of the new statute.

Park negotiated inclusion of gender identity and expression in the Dignity for All Students Act (DASA), a safe schools bill currently pending in the New York state legislature, and the first fully transgender-inclusive legislation introduced in that body. She also serves on the steering committee of the coalition that secured enactment of the Dignity in All Schools Act by the New York City Council in September 2004. Park has written widely on LGBT issues and has conducted transgender sensitivity training sessions for a wide range of social service providers and community-based organizations. She has a Ph.D. in political science from the University of Illinois at Urbana-Champaign.